MS Exam II: Elbow/Wrist

TREATMENT

3/15

Kleinart Traction

exercise by pulling against band

Picolo distraction

USE WITH ALL WRIST MOBILITIES (slight distraction)

2. Murphy's Sign

look at knuckles

Anchovy Procedure

take out trapezium, smooth down other bones. Roll up palmaris longus and put it in its space and body encapsulates it.

Ulnar Groove

ulnar nerve resides in it.

Pisiform

within the tendon of the flexor carpi ulnaris muscle

Collateral ligaments at MCP joint

*Collateral ligaments oblique at MCP joint* -MCP in extension we can ulnar and radially deviate -In flexion we CAN'T ulnar and radially deviate Because collateral ligs taught in flexion and redundant in extension Important because if in cast and can't do 90° flexion their collateral ligaments will never get to full stretch

Dorsal Compartments: 6

*ECU* - posterior interosseous nerve

Dorsal Compartments: 4

*ED*: Primary function is MP joint extension (although doesn't insert onto prox phalanx - shroud fibers encase distal part of MC and proximal part of phalanx) Inserts into middle phalanx. Central slip (top of middle phalanx) easily lacerated. *EI*: ulnar to ED (used for tendon transfers)

Dorsal Compartments: 5

*EDM* - prime MCP joint extensor but if ulnar nerve lesion, EDM can take over for abductor "wingspan"

Humeroulnar Joint Mobility Testing: Medial Gap (Valgus Strain)

*Used for testing ligamentous stability only Supine Elbow just shy of full extension STABILIZE: distal lateral humerus MOBILIZE: distal medial forearm (OUT) FORCE: Laterally directed on forearm increasing valgus angle

Humeroulnar Joint Mobility Testing: Lateral Gap (Varus Strain)

*Used for testing ligamentous stability only Supine Elbow just shy of full extension STABILIZE: distal medial humerus MOBILIZE: distal lateral forearm (IN) FORCE: Laterally directed on forearm increasing varus angle

INTRINSICS: Hypothenar Eminence

-Opponens Digiti Minimi -Flexor Digiti Minimi (flexes MCP) -Abductor Digiti MInimi -Palmaris Brevis (cupping)

Close-Packed Position of forearm

-Proximal AND distal radio-ulnar joint - supinated 5° (in this position, interosseous membrane is maximally taut)

Resting Position of forearm

-Proximal radio-ulnar joint - forearm supinated 35°, elbow flexed to 70° -Distal radio-ulnar joint - supinated 10°

Resisted Movement Testing (and muscles)

Elbow in resting position (70° flex, 10° supination) FLEXION: Biceps, Brachialis, Brachioradialis EXTENSION: Triceps, Anconeus PRONATION: Pronator teres, Pronator Quadratus, Brachioradialis SUPINATION: Supinator, Biceps, Brachioradialis

Close-Packed Position of elbow

Humero-ulnar - elbow extended and forearm supinated Humeroradial - elbow flexed to 90° and forearm supinated 5°

INTRINSICS: Lumbricals

Originates from Flexor Digitorum Profundus tendon (only one that originates from moveable origin). Inserts into -Volar to MP (flexes MP) -Joins lateral band (extends PIP and DIP)

Wartenberg Sign

POSITION: Fingers abducted, palm down on table Ask patient to abduct fingers SUBSTITUTION: POSITIVE: Unable to adduct 5th digit = ulnar neuropathy

Distraction of CMC Joints

POSITION: Hand on table STABILIZE: Carpal bones MOBILIZE: MC bone

Elbow Ligaments

Annular, MCL, LCL, Interosseus, quadrate ...

Mobility Testing: Ventral/Dorsal of Metacarpals

POSITION: Hand on table STABILIZE: Hold metacarpals with thumb and index finger along length of bone MOBILIZE: MCs around 3rd MC (ALWAYS HELD STABLE) FORCE: Dorsal/Ventral PURPOSE: ??

2. Supinated Lift Test

Ask patient to lift table with flat palm on undersurface POSITIVE: Pain or weakness

Mallet finger deformity

Can be caused by fracture or tendon...

Phalen's Test

Carpal Tunnel Syndrome

Distal Radiocarpal Joint

Condyloid joint 2°F Includes articulating disc between radius and ulnar Convex on concave in both directions (AP and mediolateral) between radius and proximal row of carpals (scaphoid and lunate) -Distal radius = concave -Articular disc = concave -Proximal row of carpals = convex

Humeroulnar Joint Mobility Testing: Distraction

CAN START HERE unless possible ligamentous laxity (then would do medial/lateral gap) Supine Elbow in resting position (70° flex, 10° supination) PT faces patient Both arms on ventral prox forearm (in elbow crease) Their hand can rest on your shoulder Move ulna away from humerus

General Mobility of Metacarpals

Convex on concave POSITION: Hand on table Grasp palmar surface with fingers and thumbs on dorsal surface MOBILIZE: splaying them apart FORCE: Spread metacarpals to reverse arch PURPOSE: Feel if any one is restricted. If it is, mobilize that joint.

Arthrokinematics of Proximal Radial-Ulnar joint

Convex radius on Concave ulna MOBILIZE in opposite direction

Mobility Testing: Radial-Ulnar Glide of 1st CMC Joint

POSITION: Hold hand against you with ulnar side down - hand in resting position STABILIZE: Trapezeii MOBILIZE: MC with key grip - dig in to be pushing out FORCE: Radially or ulnarly PURPOSE: CONCAVE ON CONVEX Radial: (restricted extension) Ulnar: (restricted flexion)

Mobility Testing: Dorsal-Ventral Glide of 1st CMC Joint

POSITION: Hold hand against you with ulnar side down - hand in resting position STABILIZE: Trapezeii MOBILIZE: MC with key grip FORCE: Dorsal/Ventral PURPOSE: CONVEX on CONCAVE Dorsal: abduction Ventral/Palmar: adduction

2. Test Method 2 - Mill's Test

POSITION: Pt. pronates, flexes wrist and extends elbow Palpate lateral epicondyle POSITIVE: Pain with stretch

1. Tennis Elbow or Cozen's Test

POSITION: Pt. pronates, radially deviates wrist and makes fist STABILIZE: Elbow TEST: Resist wrist extension POSITIVE: Pain or weakness

Inferior Radioulnar Joint Mobility Testing: Dorsal Glide

POSITION: Seated STABILIZE: Distal part of ulna from ulnar side MOBILIZE: Distal radius using thumb and index finger FORCE: Dorsal PURPOSE: Increase supination

Humeroradial Joint Mobility Testing: Dorsal glide of radial head

POSITION: Seated or Supine, forearm extended and supinated (RP of humeroradial joint) ?? (70 elbow flexion, 35 supination) STABILIZE: Dorsal aspect of distal humerus and ulna MOBILIZE: Radial head with thumb and index finger FORCE: Dorsal direction PURPOSE: Increase elbow extension

Swan Neck Deformity

Profundus tendon injured = more pull on extension and leads to hyperextension Very common in RA

MCP Joints (resting, close packed, capsular)

RESTING: Slight flexion CLOSE PACKED: Thumb full opposition, fingers full flexion CAPSULAR: Flexion>Extension

Architecture of the hand

thumb is most mobile 2nd and 3rd - firmly anchored into carpus 4th and 5th

Extrinsic Flexor Wrist Muscles - DEEP: FPL, FDP II-V

work in synergy -FDP is mass action muscle because one muscle belly separates into 4 tendons Goes through superficialis tendon and attaches at base of phalanx.

Zero Starting Position

Upper arm and forearm in frontal plane Forearm supinated and elbow straightened

MCP Joint Fractures

Want to know head, shaft or base Base involves wrist and will need splint Head involves finger and associated fingers...

Interossei movement

flexion at MP joint extend at PIP (lateral band) extend at DIP (lateral band)

Median Nerve Compression - CTS

flexor retinaculum

Strength: Pinch Strength

key, 3-draw chuck (2 lbs difference dominant vs. non-dominant)

Extrinsic Extensor Wrist Muscles

start out of hand and end in hand innervated by posterior interosseous nerve

Fossae

-Radial -Coronoid -Olecranon

Strength measurements

1. Grip strength 2. Pinch strength 3. MMT

Scaphoid-Lunate Dissociation

1. Watson Test 2. Murphy's Sign

ECRB

Attaches to 3rd MC ECRL attaches to 2/3rd MC When do tendon transfers

Active/Passive/Resisted movement testing of elbow

#s for PROM ?? Flexion: 75 Extension: 70 Radial deviation: 20 Ulnar deviation: 35

Lateral (Radial) Collateral Ligament

-Lateral ulnar collateral lig (slip to ulna) -Radial collateral lig (3 segments) -Accessory lateral collateral lig

Edema reduction

-Above heart and abduction/adduct finger -Fluid flushing massage

Medial (Ulnar) Collateral Ligament

-Anterior -Intermediate (transverse) -Posterior

Arthrokinematics of Wrist joint (flexion-Extension)

-Distal row moves first (convex on concave for all but scaphoid-trapezium/trapezoid) -Proximal row moves next (convex on concave radius and ulna) -Capitate and scaphoid move together -Capitate and lunate more dissociated -Flexion: 75% at radioscaphoid; 50% at radiolunate -Extension: 92% at radioscaphoid; 52% at radiolunate

Arthrokinematics of wrist joint (Radial and ulnar deviation)

-Distal row of carpals follow metacarpals (convex on concave at midcarpal joint) -Proximal row next (convex on concave Ulnar deviation causes radial glide of proximal row plus extension

Strength: Grip Strength

-Dynamometer - tuck elbow at side of body Dominant hand should be 10 lbs stronger (need at least 50 for ADLs - rule of thumb)

What muscles do what extension from fist to lumbrical grip? (Pg. 183 - top right picture)

-ED (fist to 90°) -Lumbricals - 90-30° (moves proximally as FDP contracts and picks up slack) -Interossei - 30° to full extension Lumbricals vs. Interossei due to line of pull - lumbrical moves proximally d/t FDP contraction

Extrinsic Flexor Wrist Muscles - Wrist: FCR, FCU, PL (92:26)

-FCR is primary wrist flexor because inserts at 3rd MC (straight line of pull for power) -FCU inserts on pisiform (ECU synergist in ulnar deviation) -PL inserts into fascia (no bony attachment)

Resting Position of elbow

-Humero-ulnar joint at 70° flexion w/ 10° supination -Humeroradial joint at full extension and supination

Ulnar nerve compression: 2 main sites

1. Cubital tunnel 2. Guyon's canal

Palmar wrist ligaments

1. Dorsal 2. Palmar 3. Radial collateral (attaches to styloid) 4. Ulnar collateral - intertwines with TFCC 5. Interosseous

1. TFCC Load Test

1. Elbow on table (and stabilize) with wrist up. Ulnarly deviate and load into table 2. Add wrist flex/ext OR pronation/supination POSITIVE: Pain, crepitus, clicking

Elbow Joints

1. Humeral-ulnar joint = Saddle 2. Humeral-radial joint = Ball and socket

SENSORY TESTING: Evaluation

1. Pain 2. Low and high frequency 3. Light touch 4. Static touch Graph it on a hand and color code it. 5. 2-point discrimination

SENSORY TESTING: Nerve and its general purpose

1. Radial nerve - preparatory 2. Median nerve - manipulation 3. Ulnar nerve - power

1. Watson Test

1. Stabilize scaphoid 2. Passively move wrist from radial to ulnar deviation POSITIVE: Pain or audible clunk

Forearm joints

1. Superior radial-ulnar joint = trochoid (pivot) joint 2. Inferior radial-ulnar joint = trochoid 3. Syndesmosis

TFCC (triangular fibrocartilage complex) Injury

1. TFCC Load Test 2. Supinated Lift Test

Tennis Elbow Tests (Lateral epicondylitis)

1. Tennis Elbow or Cozen's Test 2. Test Method 2 - Mill's Test 3. Method 3

(4/5) INTRINSICS: 3 parts

1. Thenar eminence 2. Hypothenar eminence 3. Interossei-Lumbrical Complex

Edema measurements

1. Water displacement 2. Tape measure 3. Jeweler rings

Mobility of CMC Joints

4th and 5th metacarpal comes down in fist (so have much more give than 2/3.

Subjective Examination

AREA, ONSET, NATURE, BEHAVIOR -Carrying angle (look for symmetry) -Swelling - in bursal areas (olecranon area) -Alignment of medial/lateral epicondyles (these 2 and olecranon is straight line in extension, triangle in flexion)

Flexion/Extension at Midcarpal/Radiocarpal Joint (47:15)

Acts like hinge joint extend wrist = extension at radiocarpal followed by midcarpal flexion of wrist = flexion at midcarpal followed by radiocarpal

Finger Ligaments (Pulley system of finger)

C = cruciate A = annular keep flexor tendons close to bone to give mechanical advantage. MOST IMPORTANT: A2 = base of proximal phalanx A4 = Top of middle phalanx

Finger Ligaments

Collateral ligaments oblique at MCP joint PIP & DIP collateral are TRUE - tight in flexion or extension

Arthrokinematics of Humero-radial joint

Concave on Convex

Arthrokinematics of Humero-ulnar joint

Concave on convex

Arthrokinematics of Distal Radial-Ulnar joint

Concave radius on convex ulna MOBILIZE in same direction

Active/Passive Movement Testing

DIP flexion: 0-90° PIP flexion: 0-120° MCP flexion: 0-90° *Hyperextension is an issue - measure this MCP extension highly variable

Finkelstein's Test

DeQuervain's Disease 1. Patient grasps thumb and maintains flexion at MCP 2. Add ulnar deviation POSITIVE: Pain along course of APL or EPB

INTRINSICS: Thenar Eminence

Divide into (divider is FPL): 1. Positioners (radial side) -Opponens Policis (not power) -Abductor policis brevis (flexes MP and extension of IP, palmar abduction) -Flexor Pollicis Brevis (superficial head - flexion of MP) 2. Pinch (ulnar side) -Abductor Pollicis -Flexor Pollicis Brevis (deep head) -1st Dorsal Interossei

Thumb Spica Splint for Dequervain's tenosynovitis

Don't need to splint IP joint because EPB and APL don't extend to IP joint

Dorsal Compartments: 2

ECRB (stronger due to straight line of pull) ECRL

Which tendon do they take for tendon transfers from extensors?

ECRL because it attaches to both 2/3rd MC and ECRB only attaches to 3rd MC. Don't want you going into radial deviation when you want pure wrist extension (43:30)

Passive Movement Testing

ELBOW Flexion Extension - put hand on distal inferior humerus for end feel FOREARM (neutral flexed at 90° - grip w/ both hands and twist body) Pronation Supination

Active Movement Testing (3/9)

ELBOW Flexion - 140-150° Extension - 0° FOREARM (neutral flexed at 90°) Pronation - 80-90° Supination 90°

Dorsal Compartments: 1

EPB, APL Lie on top of radial styloid (osteophytes, fracture etc - fragile area) Dequervain's - tenosynovitis of this compartment.

Dorsal Compartments: 3

EPL (lister's tubercle) -Posterior interosseous nerve

Resisted Movement Testing

Flexion: FDS, FDP, lumbricals, FPL, FPB Extension: EDC, EDM, EI, EPL EPB Abduction: Interossei, ADM Adduction: Interossei

End Feels

Extension = Bone on bone Flexion = soft tissue Pronation = hard (bone on bone) Supination = Abrupt and firm

Lister's Tubercle

Extensor Pollicis Longus (can get osteophytes on the tubercle)

ROM of Radiocarpal and Midcarpal joints

FLEXION: 85° -Midcarpal: 35° -Radiocarpal: 50° EXTENSION: 85° -Midcarpal: 35° -Radiocarpal: 50°

Scaphoid fracture

FOOSH - different types <30 >30 you fracture distal radius (end of long bones demineralize...) Get casted above wrist (stop pro/sup) for up to 6 mo

Midcarpal Joint

FUNCTIONAL UNIT - not synovial joint between rows of carpals HINGE JOINT -Scaphoid (convex) articulates with trapezium and trapezoid -Lunate (concave) with capitate -Triquetrium (concave) with hamate

Capsular Pattern of Elbow

Flexion > extension (approx 90° flexion to 10° extension)

Smith Fracture

Flexion fracture of radius

Boxer's Fracture

Fracture of 5th MCP Impaction of distal MC and rotation (?)

How do FDP/FDS get blood supply?

Gets blood supply through vincula web

RESTING POSITIONS (check that above are these)

HUMEROULNAR: flexed 70, supinate 10 HUMERORADIAL: elbow flexed 70, supinate 35 (go with this) PROXIMAL RU: elbow flexed 70, supinate 35 DISTAL RU: forearm supinated 10

Hamate

Has hook of hamate - protects ulnar nerve. Fx of hook of hamate can cause ulnar nerve damage Karate damage.

*Tourniquet Test

Inflate BP cuff to 200mmHg Pain or parasthesia = positive

INTRINSICS: Interossei

Interossei - ulnar innervated - between MCP -3 Volar - unipennate - adduction -4 Dorsal - bipennate in nature - abduction

If patient lacks full terminal finger flexion - how would you determine which structures are tight? (28:30)

Intrinsic tightness test - keep wrist in neutral 1. Passively flex MCP joint and has tightness 2. Passively flex PIP and DIP together tightness in 2 then it's ED tendon (stretching it over) Confirm by passively extending MCP joint (puts slack on ED tendon but intrinsics tight)

Palpation: Radial styloid process, Lister's tubercle, ulnar styloid process (3/22)

LT - in line w/ 3rd MC (slide down and flexed wrist and lunate pops up) snuff box and ulnarly deviate = scaphoid

Scaphoid vs. Lunate and Triquetrium surfaces

Lateral part: Planar Medial part: Condylar

Finger Joints (MP/IP)

MP Joint: Condyloid (2° - F/E, Ab/Add) IP Joint: Hinge (1° - F/E)

Darrach procedure

Management for RA -Ulnar head is excised because it has osteophytes and tendons gliding over the head and can rupture.

CMC Joints

Modified saddle joint (side-side and front-back)

Lunate dislocation

Most common hand dislocation See angle of "C" change on x-ray.

Trapezium

Most likely to develop OA

Treating elbow mobility issues

No passive stretching Can do active assistive, Contract-Relax etc.

Humeroradial Joint Mobility Testing: Ventral glide of radial head

POSITION: Seated or Supine, forearm extended and supinated (RP of humeroradial joint) ?? (70 elbow flexion, 35 supination) STABILIZE: Ventral aspect of distal humerus and ulna MOBILIZE: Radial head with thumb and index finger FORCE: Dorsal direction PURPOSE: Increase elbow flexion

Superior Radial Ulnar Joint Mobility Testing: Dorsal and ventral glide of radial head

POSITION: Seated, elbow flexed to 70, supinated to 35 STABILIZE: Distal humerus and ulna MOBILIZE: Radial head with thumb and index finger FORCE: Volar/dorsal PURPOSE: (opposite directions) Ventral = increase supination Dorsal = increase pronation

Inferior Radioulnar Joint Mobility Testing: Ventral Glide

POSITION: Seated, forearm in resting position STABILIZE: Distal part of ulna from ulnar side MOBILIZE: Distal radius using thumb and index finger FORCE: Ventral PURPOSE: Increase pronation

Mobility Testing: Dorsal/Ventral Glides of MCP, PIP, DIP

POSITION: Seated, hand palm down, finger in resting position STABILIZE: Patients hand against your body, just proximal to joint evaluating MOBILIZE: Distal joint FORCE: Dorsal/ventral PURPOSE: Dorsal = extension Ventral = flexion

Mobility Testing: Distraction of MCP, PIP, DIP

POSITION: Seated, hand palm down, finger in resting position STABILIZE: Patients hand against your body, just proximal to joint evaluating MOBILIZE: Distal section FORCE: Traction PURPOSE: General joint mobility

Mobility Testing: Radial Glides of MCP, PIP, DIP

POSITION: Seated, palm facing PT, fingers in resting position STABILIZE: Patients hand against your body, just proximal to joint evaluating MOBILIZE: Distal joint FORCE: Radially PURPOSE: Overall joint mobility

Mobility Testing: Ulnar Glides of MCP, PIP, DIP

POSITION: Seated, palm facing PT, fingers in resting position STABILIZE: Patients hand against your body, just proximal to joint evaluating MOBILIZE: Distal joint FORCE: Ulnarly PURPOSE: Overall joint mobility

Humeroulnar Joint Mobility Testing: Lateral Glide (alternative)

POSITION: Sidelying (flexed 70, supinate 10) STABILIZE: Distal Humerus on wedge MOBILIZE: Proximal medial forearm in lateral direction PURPOSE: Overall joint play

Radiocarpal Joint: Radial Glide

POSITION: Sitting, forearm on radial aspect STABILIZE: Forearm proximal to wrist on ulnar side MOBILIZE: Proximal carpals FORCE: Radial direction PURPOSE: Ulnar deviation

Radiocarpal Joint: Ulnar Glide

POSITION: Sitting, forearm on ulnar aspect STABILIZE: Forearm proximal to wrist on radial side MOBILIZE: Proximal carpals FORCE: Ulnar direction PURPOSE: Radial deviation

Midcarpal Joint: Distraction

POSITION: Sitting, forearm pronated STABILIZE: Proximal row of carpals MOBILIZE: Distal row of carpals FORCE: Distaly PURPOSE: General joint mobility

Midcarpal Joint: Ventral Glide

POSITION: Sitting, forearm pronated STABILIZE: Proximal row of carpals MOBILIZE: Distal row of carpals FORCE: Ventrally PURPOSE: Flexion

Radiocarpal Joint Distraction

POSITION: Sitting, forearm pronated, wrist in resting position STABILIZE: Forearm proximal to wrist MOBILIZE: Proximal carpals FORCE: Distally PURPOSE: General mobility

Radiocarpal Joint: Palmar Glide

POSITION: Sitting, forearm pronated, wrist in resting position over edge of table STABILIZE: Forearm proximal to wrist MOBILIZE: Proximal carpals FORCE: Palmar direction PURPOSE: Extension

Midcarpal Joint: Dorsal Glide

POSITION: Sitting, forearm supinated STABILIZE: Proximal row of carpals (on wedge) MOBILIZE: Distal row of carpals FORCE: Dorsally PURPOSE: General joint mobility - Extension

Radiocarpal Joint: Dorsal Glide

POSITION: Sitting, forearm supinated, wrist in resting position over edge of table STABILIZE: Forearm proximal to wrist MOBILIZE: Proximal carpals FORCE: Dorsal direction PURPOSE: Flexion

Humeroradial Joint Mobility Testing: Distraction

POSITION: Supine, Resting position (70 flex, 35 supination) STABILIZE: Volar aspect of distal humerus (and palpate radial head) MOBILIZE: Distal radius (key grip - forearm in line of pull) FORCE: Longitudinal traction and inferior glide PURPOSE:

Humeroradial Joint Mobility Testing: Compression/Approximation

POSITION: Supine. Elbow flexed to 90° STABILIZE: Distal lateral humerus (and palpate radial head) MOBILIZE: Thenar eminences in contact (forearm in line of pull) FORCE: Longitudinally approximate radius to humerus PURPOSE:

Capsular Pattern of Forearm

Pronation and supination equally restricted (only occurs when flexion and extension restricted)

IP Joints (resting, close packed, capsular)

RESTING: Slight flexion CLOSE PACKED: Full extension CAPSULAR: Flexion>Extension

CMC Joints (resting, close packed, capsular)

RESTING: Slight flexion CLOSE PACKED: Thumb full opposition, fingers full flexion CAPSULAR: Flexion>Extension

Proximal Scaphoid Injury

Reason fracture is so common is it's in line with lunate and triquetrium. *Interconnecting link between proximal and distal row* Hinge joint and scaphoid not... Don't see on x-rays for awhile

Surgery for tendon inflammation

Release compartment - just cut it. Still inflamed. BUT be careful in 1st dorsal compartment (superficial branch of radial nerve can be cut)

3. Method 3

Resist 3rd finger proximal to PIP joint causing stress on EDL muscle and tendon POSITIVE: Pain at lateral epicondyle

Golfer's Elbow Test (Medial epicondylitis)

Resisted flexion of wrist is painful Stretch into supinaton with elbow and wrist extension

Humeroulnar Joint Mobility Testing: Medial Glide (alternative)

Sidelying POSITION: pt in ER (flexed 70, supinate 10) STABILIZE: Forearm with wedge (or hold with hand) MOBILIZE: DIstal humerus to floor

Mobility Testing: Around Capitate

STABILIZE: Capitate MOVE: Trapezeii, scaphoid, lunate, hamate

Mobility Testing: Carpal Bone Mobility - Radial Side

STABILIZE: Scaphoid MOBILIZE: 2 Trapezeii

Mobility Testing: Carpal Bone Mobility - Ulnar Side

STABILIZE: Triquetrium MOBILIZE: Hamate STABILIZE: Triquetrium MOBILIZE: Pisiform

1st CMC Joint (arthrokinematics)

Saddle (2° - F/E: Concave on convex) (Abd/Add - Convex on concave) PICTURE

Supination/Pronation after fracture

Supination tougher because interosseous membrane is shortened after casting (casted in pronation)

Humeroulnar Joint Mobility Testing: Lateral Glide

Supine/Seated flexed 70, supinate 10 STABILIZE: Distal lateral humerus MOBILIZE: Proximal medial forearm in lateral direction

Humeroulnar Joint Mobility Testing: Medial Glide

Supine/seated flexed 70, supinate 10 STABILIZE: medial distal humerus MOBILIZE: Lateral proximal forearm in medial direction PURPOSE: Overall joint play

Tinel's Sign

Tap w/ reflex hammer POSITIVE = pain or parasthesia in median nerve distribution

Hematoma

Travel distally - could be sign of previous fx more proximal

Extrinsic Flexor Wrist Muscles

Wrist: FCR, FCU, PL DEEP: FPL, FDP II-V SUPERFICIAL: FDS

Midcarpal joint (zero starting, resting, closed packed position, capsular pattern)

ZERO: RESTING: Neutral or slight flexion w/ ulnar deviation CLOSE PACKED: Extension w/ ulnar deviation CAPSULAR: Equal in flexion and extension

Radiocarpal joint (zero starting, resting, closed packed position, capsular pattern)

ZERO: Longitudinal axes through radius and 3rd MCP RESTING: Longitudinal axes through radius and 3rd MCP straight w/ a little ulnar flexion CLOSE PACKED: Extension CAPSULAR: Equal in all directions

Purpose of Volar Plate

at MCP joint Anchored distally and goes into fascia proximally. Can hyperextend at MCP joint because of its anchor into fascia. at PIP & DIP joint - bone proximally and distally

Triangular Fibrocartilage Complex (TFCC)

bounded by dorsal and palmar radial and ulnar ligaments...

Boutonniere Deformity

hyperflexion at PIP with extension of DIP Volar plate will get tight quickly

Extrinsic Flexor Wrist Muscles - SUPERFICIAL: FDS

most likely to be sliced first

All deep muscles are innervated by...

ulnar nerve *Strength of the hand*

With RA, hand deviates _______

ulnarly -ED tendon no longer held by transverse ligaments (destroyed) and falls ulnarly. Can't be fixed with splinting